Project Summary/Abstract It could be said that many dementia care and caregiver support interventions are too limited, focusing solely on psychosocial and behavioral issues. These issues are important, but so too is the physical health of people with dementia -- especially because they are living longer and require even more support with health care and activities of daily living. Just imagine the benefit of a physical health care intervention provided daily. Case in point: tooth brushing, flossing, and gum and denture care. Many people with dementia resist mouth care ? almost 90% in nursing homes, in fact. As a result, only 16% have their teeth brushed regularly, putting them at risk for aspiration pneumonia when they inhale bacteria from their teeth, tongue, and gums. In 2013, the research team submitting this proposal developed one of the two existing dementia-focused mouth care programs for nursing homes -- Mouth Care Without a Battle (MCWB) -- which already has become a standard of nursing home care. MCWB changes caregivers' attitudes and behavior, improves oral health, and in a cluster randomized trial, MCWB provided by nursing assistants reduced pneumonia incidence by 32 percent. The next frontier is to extend MCWB to assisted living (AL), the primary long-term residential care provider for persons with dementia. There are 30,200 AL communities across the country. As many as 90% of the 835,200 AL residents have cognitive impairment, and 42% have moderate or severe dementia (and on average, five untreated oral health conditions/person), meaning MCWB has the potential to improve the health and quality of life of more than 350,000 AL residents with dementia annually. There is a unique and timely opportunity to transform MCWB for AL, given the North Carolina Department of Health and Human Services (DHHS) Special Care Dentistry Program's partnership in this effort. This nested cohort cluster randomized trial will apply the NIH Stage Model and principles of the Science of Behavior Change to lay the groundwork for a pragmatic trial and real-world implementation of MCWB for AL residents with dementia and their caregivers. The aims are to refine MCWB for AL, and examine research efficacy (working with a research dental hygienist) and real-world efficacy (working with community public health dental hygienists) to train personal care aides in 48 AL communities across North Carolina to provide mouth care; the project will include 720 residents with dementia, 348 AL staff, and 24 dental hygienists. Evaluation will address (1) the reach of the intervention; (2) effects on mediators/targets of change at the organizational and individual level; (3) outcomes (oral hygiene, pneumonia, hospitalizations); (4) associations between change at the organizational and individual level and outcomes, and also associations with characteristics of the AL community and staff; and (5) attitudes, barriers, and facilitators. By the conclusion of this project, MCWB will be ready for evaluation in a pragmatic trial of AL residents with dementia and the staff who provide their care.